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3urnett County Office of Zoning Administrator 0) CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE -- BUILDING PERMIT 3. <br /> o ?\ <br /> FO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as Z <br /> hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCD <br /> grdinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- <br /> OHS �- • egip <br /> — � o <br /> CD <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT CD CD <br /> CL <br /> L.�11- ^a <br /> aDDRE S ADDRESS h ' <br /> t`'� �.. ..�a.3................ ............................................................................................ �s <br /> ................. <br /> kDDRESS J ADDRESS �— <br /> . .......................................... ............................................................................................ <br /> 'HO PHONE <br /> t � L` <br /> r ...P7 '>p.![..kh.S...................................................... <br /> 'LU BER WELL DRILLER <br /> AD......D.RES"'E'S" ......................................................................... _. <br /> ADDRESS S.. Cl) o :r <br /> z o <br /> O E r <br /> 'HONE PHN <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms 1•... 4I� o <br /> New Building .... Type of Construction: No. Bedrooms .... <br /> Addition Septic Tank Size Gals. ......... r%% <br /> Sanitary ••. Size ... . ..�ft. x ....AS... ft. <br /> Filling .......... Height....l. .... Stories ... ........ <br /> 4a. Absorption Field Site: <br /> Moving Area ........................................... <br /> Soil Type r— <br /> Grading u <br /> .......... Slope .......................................... <br /> Mobile Home Perc. Rate p� <br /> 3. Use (describe exactly, 1 family ••••••........................••••• <br /> Privy ..•, home,garage, motel, etc.) Dry Well •••••••••• <br /> Well !.M.t.4.Y....kr4K ...Y0105 Seepage Trench .......... <br /> Subdivision <br /> Privy ' <br /> .......... <br /> Seepage Bed �0 x <br /> -------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road '�' <br /> 1 � <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o <br /> ;ection, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> H <br /> ------------------------------------- ---------------- <br /> 5. L • e: Fig. A. 6. Location: Q h <br /> il. ...... ft. x .. 7.. ft. sq.ft. <br /> — E <br /> o <br /> cn :� <br /> N <br /> rF <br /> G� <br /> vN N <br /> 7. <br /> _• jJ o <br /> CD <br /> ` c co <br /> t IN It et <br /> O 7 — <br /> 11 <br /> ....... ....... ............ ...... s.:-. 9..- .y.... o <br /> 51 ture of Owner or Agent Date X <br /> emarks .•,Well must be at least 50 feet from drainfield. -n o m <br /> �eA.... --:.......................................................................................................................... <br /> . ....................................... �............................ w . . . <br /> Inspection Date r� ...... ....... ......... ............ ...........�J............ cn T <br /> �/ o: N m <br /> p GG�G�✓ Zoning Admini trator ( E o 0 0 0 o fm/) <br /> coo 00 <br /> TOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> iith is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />